AMA battles insurers over doctor ratings: The nation’s largest doctors’ group criticized insurers’ efforts to steer patients to doctors they consider to offer the best care for the lowest price. [Star Tribune, Minneapolis]

July 20--The nation's largest doctors' group on Monday criticized insurers' efforts to steer patients to doctors they consider to offer the best care for the lowest price.

A letter that the American Medical Association sent major insurers reflects doctors' concerns about a practice that is expected to spread as insurers compete to offer cheaper coverage to millions of Americans as health reform rolls out.

Insurers steer members by making them pay more to use doctors rated as less efficient, based on quality of care and cost. But the AMA says the ratings are often inaccurate.

"Physicians' reputations are being unfairly tarnished using unscientific methodologies and calculations," the AMA said in the letter.

Based on the ratings, some patients are offered financial incentives to leave their longtime doctors, said AMA President Dr. Cecil Wilson. Yet a recent RAND Corp. study showed such measures can be wrong more than 25 percent of the time, he said.

A total of 47 state medical societies signed the letter. The Minnesota Medical Association was not among them, but it has raised similar concerns in the past.

The letter is an example of the kind of conflict that will inevitably arise as the government, insurers and doctors struggle to control costs while adding 32 million Americans to the insured population.

"There's increasing pressure to do something about not wasting resources when it's not useful, but it's not always black and white," said Jim Chase, executive director of Minnesota Community Measurement, a state health care quality organization.

Ratings may be deceiving

The AMA is particularly worried about individual physicians being rated by insurers. The doctors' group says physicians who are deemed expensive may be looking after sicker patients, or the claims data may simply be inaccurate.

To complicate things, ratings can differ from one insurance company to another. "One company thinks they're wonderful, another company thinks they're not so wonderful and they're all using the same claims data," Wilson said.

The AMA is asking insurers to re-evaluate their rating programs and subject them to external review.

Insurers say the ratings not only help members make informed choices but also push doctors to improve care to raise their rating.

Doctor ratings have come under scrutiny before. A few years ago, New York Attorney General Andrew Cuomo investigated claims that insurers were using ratings to send patients to cheaper doctors rather than better ones.

That led to a 2007 agreement with national health insurers, including Minnetonka-based UnitedHealth Group. The insurers agreed to ensure doctors met quality goals before they were evaluated on cost.

External review

UnitedHealth spokesman Tyler Mason said Monday that the company's doctor rating system is already subject to external review, including by the doctors themselves.

Before the information is released to the public, a physician can challenge and appeal the rating, Mason said, adding: "At the end of the day, it's consumers and employers who want access to this information."

The issue is unlikely to go away soon because there are limits to the ways insurers can keep premiums down.

The obvious ones are to raise out-of-pocket costs or to narrow the choice of providers.

Tiered networks use both, by steering patients using different levels of co-pays and co-insurance.

Twenty years ago, managed care companies achieved the same goal with narrow provider networks but "those don't work any more for consumers," said Eileen Smith, a spokeswoman for the Minnesota Council of Health Plans. "People want to be able to choose their own doc."

Wilson said he expects more competition among insurers as they offer new products on health insurance exchanges that are to be set up as part of President Obama's national health care overhaul.

Controlling costs

While this is likely to offer better prices and more choice, "we think it's important to recognize that the drive for controlling cost has potential to do things in the name of cost that make quality worse," Wilson said.

Dr. Robert Meiches, president of the Minnesota Medical Association, said he shares the AMA's concerns but decided not to sign the letter for a couple of reasons.

For one thing, Minnesota already measures physicians for cost and quality by group, not individually.

Secondly, the MMA has been working with the state on a way to collectively analyze all commercial insurance claims to come up with a single set of measurements for physician groups and clinics.

"We're going to find out this fall" if that works, Meiches said.

Yet while doctors are understandably worried about being misclassified as high-cost or low-quality, for patients some information may be better than no information, said Chase of Minnesota Community Measurement.

"For patients, the probability of getting a low-cost provider is a random shot right now," Chase said. "An argument for the future may be: 'When is the data good enough?'"

Chen May Yee --612-673-7434

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